| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,709 |
2,085 |
$271K |
| D1120 |
Prophylaxis - child |
5,425 |
5,425 |
$189K |
| D0120 |
Periodic oral evaluation - established patient |
7,314 |
7,314 |
$169K |
| D1110 |
Prophylaxis - adult |
3,041 |
3,041 |
$150K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,831 |
1,587 |
$150K |
| D1206 |
Topical application of fluoride varnish |
5,896 |
5,896 |
$96K |
| D0272 |
Bitewings - two radiographic images |
4,445 |
4,445 |
$83K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,338 |
2,267 |
$76K |
| D0220 |
Intraoral - periapical first radiographic image |
5,538 |
5,516 |
$70K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,564 |
4,751 |
$68K |
| D0330 |
Panoramic radiographic image |
1,360 |
1,360 |
$63K |
| D0274 |
Bitewings - four radiographic images |
1,780 |
1,780 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,091 |
2,091 |
$34K |
| D7140 |
Extraction, erupted tooth or exposed root |
223 |
122 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
433 |
433 |
$17K |
| D1351 |
Sealant - per tooth |
255 |
53 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
56 |
52 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
96 |
96 |
$3K |
| D7111 |
|
15 |
12 |
$999.00 |